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Degeneration of mitral prostheses/rings may be treated by redo surgery, and, recently, by transcatheter valve-in-valve/ring implantation. This multicenter registry presents results of transcatheter valve-in-valve and repeat surgery for prostheses/rings degeneration.Data provided by 10 German heart centers underwent propensity score-matched retrospective analysis. The primary endpoint was 30-day/midterm mortality. Perioperative outcome was assessed according to the Mitral Valve Academic Research Consortium criteria. Further, the influence of moderate or greater tricuspid regurgitation (TR) on 30-day/midterm mortality was analyzed.Between 2014 and 2019, 273 patients (79 transcatheter mitral valve-in-valve [TM-ViV] and 194 redo mitral valve replacement [Re-MVR]) underwent repeat procedure for mitral prosthesis/ring degeneration. Propensity score matching distinguished 79 patient pairs. European System for Cardiac Operative Risk Evaluation (EuroSCORE) II-predicted risk was 15.7 ± 13.7% in the TM-ViV group and 15.0% ± 12.7% in the Re-MVR group (P = .5336). TM-ViV patients were older (74.73 vs 72.2 years; P = .0030) and had higher incidence of atrial fibrillation (54 vs 40 patients; P = .0233). Severe TR incidence was similar (17.95% in TM-ViV vs 14.10%; P = .1741). Sixty-eight TM-ViV patients previously underwent mitral valve replacement, whereas 41 Re-MVR patients underwent valve repair (P .0001). Stenosis was the leading degeneration mechanism in 42 TM-ViV versus 22 Re-MVR patients (P .0005). The 30-day/midterm mortality did not differ between groups. Moderate or greater TR was a predictor of total (odds ratio [OR], 4.36; P = .0011), 30-day (OR, 3.76; P = .0180), and midterm mortality (OR, 4.30; P = .0378), irrespective of group.In both groups, observed mortality was less than predicted. Redo surgery enabled treatment of concomitant conditions, such as atrial fibrillation or TR. TR was shown to be a predictor of total, 30-day, and midterm mortality in both groups.

Introduction: Transcatheter aortic valve-in-valve implantation (TAVI-ViV) can be associated with unfavorable hemodynamic outcomes. This study aimed to estimate the prevalence, identify the risk factors, and evaluate the outcomes and survival of patients with high residual gradients after TAVI-ViV. Methods: A total of 85 patients were included in the study. The cohort was divided into group A, with postprocedural mean pressure gradient (PG) ≥ 20 mmHg, and group B, with mean PG < 20 mmHg. Results: Postprocedural PG ≥ 20 mmHg was observed in 24.7% of the patients. In a univariate analysis, preoperative gradient, pre-existing patient-prosthesis mismatch (PPM), deep valve implantation, small degenerated valves, and an older generation of transcatheter aortic valves were found to be risk factors for high residual gradient. Multivariate analysis showed that preexisting maxPG > 60 mmHg, implantation level of 4 mm below neo-annulus, and degenerated valve size ≤ 23 mm were independent predictors of high residual gradient. There were no differences in early morbidity (myocardial infarction, pacemaker implantation, stroke, acute renal insufficiency) between groups. Kaplan-Meier estimated that the survival rate was comparable at one and five years regardless of postoperative gradient. Survivors with high residual mean gradient were significantly affected by a high New York Heart Association (NYHA) class. Conclusion: High residual transvalvular gradient after TAVI-ViV is not rare, but it does not significantly affect mortality. High residual mean gradient has a negative impact on NYHA functional class improvement after the procedure. High preoperative gradient, implantation level, and small failed bioprosthesis may predispose to increased residual gradient.

Background: Demographic changes have led to an increase in the proportion of older patients undergoing heart surgery. The number of endocarditis cases is also steadily increasing. Given the sharp increase in patients who have received valve prostheses or electrophysiological implants, who are on chronic dialysis or taking immunosuppressants, the interdependence of these two developments is quite obvious. We have studied the situation of older patients suffering from endocarditis compared to younger ones. Are they more susceptible, and are there differences in outcomes? Patients and Methods: A total of 162 patients was studied from our database, enrolled from 2020 to 2022. Fifty-four of them were older than 75 years of age (mean age 79.9 ± 3.8 years). The remaining 108 patients had a mean age of 61.6 ± 10.1 years. EuroSCORE II (ES II) was higher in the older patients (19.3 ± 19.7) than in the younger ones (13.2 ± 16.84). The BMI was almost identical. The preoperative NYHA proportions did not differ. A statistical analysis was performed using R. Results: Older patients had a lower left ventricular ejection fraction (LVEF), a higher proportion of coronary heart disease (CHD), a higher amount of N-terminal probrain natriuretic peptides (NT-proBNPs), worse coagulation function, worse renal function than younger patients, and were more often valve prosthesis carriers compared to the younger patients. The diagnostic interval was 66.85 ± 49.53 days in the younger cohort, whereas it was only 50.98 ± 30.55 in the elderly (p = 0.081). Significantly fewer septic emboli were observed in the older patients than in the younger patients, but postoperative delirium and critical illness polyneuropathy and critical illness myopathy (CIP/CIM) were observed significantly more frequently compared to younger patients. In-hospital mortality was higher in older patients than in younger patients, but did not reach statistical significance (29.91% vs. 40.38%; p = 0.256). The postoperative clinical status was worse in older patients than in the younger ones (NYHA-stage, p = 0.022). Conclusions: Age did have an impact on the outcome, probably due to causing a higher number of cumulative preoperative risk factors. However, an interesting phenomenon was that older patients had fewer septic emboli than younger patients. It can only be speculated whether this was due to a shorter diagnostic interval or lower mobility, i.e., physical exertion. Older patients suffered more frequently than younger ones from typical age-related postoperative complications, such as delirium and CIP/CIM. In-hospital mortality was high, but not significantly higher compared to the younger patients. Considering the acceptable mortality risks, and in light of the lack of alternatives, older patients should not be denied surgery. However, individual consideration is necessary.

Thoracoscopic atrial fibrillation ablation seeks to replicate the electrophysiological effects of more invasive, open surgical procedures. The authors present a lesion concept that includes isolation of the pulmonary veins, the left atrial posterior wall, and the superior vena cava, respectively, lines to inhibit perimitral and periauricular flutter circuits, and left atrial appendage closure. All lesions are tested for bidirectional block.

Background: Patients with left ventricular ejection fraction (LVEF) ≤ 35% are at a high risk of sudden cardiac death (SCD) and benefit from implantable cardioverter-defibrillator (ICD) therapy. ICD implantation is not indicated during the first 40 days after acute myocardial infarction and Methods: This is a retrospective study conducted in the Heart Center in Cottbus. From 02.2015 through 02.2018 26 WCD patients were retrospectively analyzed and followed-up. Patient demographics, defibrillation treatments, and daily wear times were retrospectively obtained from our clinical database and LifeVest network. The patients were questioned about actual NYHA grade and implanted ICD at the end of follow-up. Results: Twenty-five patients (mean age 65, 22 men, 3 women) were treated with a WCD in response to heart failure (mean EF = 24%) after cardiac surgery (21 CABG, 1 AVR, 1 AVR + CABG, 1 AVR + MVR, MVR + CABG). Average daily use of a WCD was 22.1 (SD ± 2.7) hours which were worn for 85 days (SD ± 35). At that time 11.96 (SD ± 15) events were detected but not treated, 1 defibrillation performed and no asystole seen. At the end of follow-up (12 months, SD ± 9) 20 patients were questioned. All of the patients were alive and 5 (25%) of them were with implanted ICD. 10 (50%) patients were in NYHA grade I, 3 (12%) in NYHA grade II, 3 (12%) between grade II-III, 2 (8%) in grade III and 2 (8%) patients in NYHA grade IV. Conclusions: A WCD is an effective therapy for prevention of sudden cardiac death during the recovery period of heart function after cardiac surgery. This is treatment with high patient compliance.

Epicardial Convergent ablation followed by endocardial touch-up and an additional ablation may be superior to catheter-based interventions in patients with persistent atrial fibrillation. We sought to extend the epicardial lesion set by changing the standard subxiphoid thoracotomy to a left-lateral, totally thoracoscopic approach. This tutorial depicts a closed-chest, beating-heart procedure, including ablation of the left atrial posterior wall, the left atrial dome, and the left pulmonary veins. The left atrial appendage is closed using an epicardial occlusion device.

Background The relationship between preoperative cardiac conduction abnormalities (CCA) and long-term outcomes after transcatheter aortic valve-in-valve implantation (TAVI-VIV) remains unclear. The aim of the study was to evaluate the effects of preoperative CCA on mortality and morbidity after TAVI-VIV and to estimate the impact of new-onset CCA on postoperative outcomes. Methods Between 2011 and 2020, 201 patients with degenerated aortic bioprostheses were qualified for TAVI-VIV procedures in two German heart centers. Cases with previously implanted permanent rhythm-controlling devices were excluded (n = 53). A total of 148 subjects met the eligibility criteria and were divided into 2 study groups according to the presence of preexisting CCA (CCA (n = 84) and non-CCA (n = 64), respectively). Early and late mortality and morbidity were evaluated. Follow-up functional status was assessed according to New York Heart Association (NYHA) classification. Results There were no procedural deaths. TAVI-VIV related new-onset CCAs were observed in 35.8% patients. The 30-day permanent pacemaker implantation rate was 1.6% in non-CCA vs 9.5% in CCA group (p = 0.045). Preexisting right bundle-branch block (OR:5.01; 95%CI, 1.05–23.84) and first-degree atrioventricular block (OR:4.55; 95%CI, 1.10–18.73) were independent predictors of new pacemaker implantation. One-year and five-year probability of survival were comparable in CCA and non-CCA groups: 90.3% vs 91.8% and 68.2% vs 74.3%, respectively. Surviving patients with preexisting and new-onset CCA had a worse functional status according to NYHA classification at follow-up. Conclusion Preexisting and new-onset postoperative CCAs did not affect early and late mortality after TAVI-VIV procedures, however, they may have a negative impact on late functional status.

Objectives The aim of this study was to evaluate outcomes of valve-in-valve transcatheter aortic valve implantation (VIV-TAVI) in patients with degenerated small bioprostheses. Methods Outcomes of consecutive 27 high-risk patients (logistic EuroSCORE 35.5 ± 18.5%) with a mean age of 81.0 ± 5.9 years who underwent VIV-TAVI for degenerated small bioprostheses (19 mm-11.1%; 20 mm-11.1%; 21 mm-77.8%) were analyzed. Medtronic CoreValve (n = 11) or CoreValve Evolut-R prostheses (n = 16) were implanted. Follow-up was 3.2 ± 2.0 years. Results Early mortality was 11.1%. One patient died intraoperatively due to left ventricle perforation, two others during the in-hospital period as a result of sudden cardiac death and pulmonary embolism. VIV-TAVI was completed in 26 cases (96.3%-success rate). Two patients required pacemaker implantation. Acute kidney injury occurred in two other patients. At discharge, mean transvalvular gradient was 19.2 ± 9.5 mmHg and in 25.9% of patients mean gradient exceeded 20 mmHg. Overall mortality was 25.9% and mortality from cardiac or unknown causes at 18.5%. Ninety percent of survivors were in New York Heart Association (NYHA) class I or II. Conclusions Transfemoral VIV-TAVI in patients with small, degenerated bioprostheses appears to be a promising alternative to surgery. Although the vast majority of patients have significant improvement in their NYHA class, the rate of persistent, residual gradients is relatively high and will need to be followed closely with serial echocardiograms.

Optimal treatment for residual mitral regurgitation (MR) after MitraClip failure is not clearly defined. We report our clinical experience and discuss treatment options. Between January 2013 and January 2018, 37 patients (75 ± 8.9 years, 46% male) were admitted for symptomatic MR (grade 3.1 ± 0.47) diagnosed after previous MitraClip therapy. Clinical outcome of these patients, who underwent medical therapy alone (n = 8, M-group), repeat MitraClip therapy (n = 8, reMC group), or mitral valve surgery (n = 21, S-group) for residual MR, were retrospectively analyzed. Thirty-day survival was 88% (M-group), 100% (reMC-group), and 76% (S-group). The rate of discharge to home was 88% in the reMC-group, better than 38% in the M-group (p = 0.051) and 19% in the S-group (p

A device-related thrombus is a very common complication after the implantation of a Watchman device. Although anticoagulation therapy is the standard first choice therapy for a device-related thrombus, complications related to bleeding or existence of non-responders to the anticoagulation therapy are reported. Therefore, the possibility of another treatment, including surgical repair, needs to be discussed in the population unsuccessfully treated with anticoagulation therapy. We performed device-related thrombus removal and covered the orifice of the left atrial appendage with an autologous pericardial patch in 2 cases involving non-responders to anticoagulation therapy. Herein, we describe the technique and results of our experience with these 2 patients. The covering technique with an autologous pericardial patch is simple but highly efficient in preventing recurrent thrombus formation.

AimTo evaluate the impact of preinterventional moderate-to-severe functional tricuspid regurgitation (FTR) on early outcome after percutaneous edge-to-edge mitral valve repair (pMVR) with MitraClip procedures for functional mitral regurgitation (FMR) in patients with heart failure with reduced ejection fraction (HFrEF).Methods and resultsFrom January 2013 to December 2017, 80 patients with HFrEF (ejection fraction 22%±5.3%) and FMR (grade 3.0±0.36) underwent successful pMVR. The 3-year actuarial survival was 58%. However, 73% (n=22) of non-survivors died of cardiac failure within 1 year. Patients were categorised into none-to-mild (n=36) and moderate-to-severe (n=44) postinterventional FTR groups according to pre-MitraClip tricuspid regurgitation grade. Cox regression analysis on 1-year survival demonstrated an impact of FTR severity (HR=1.8, 95% CI 1.01% to 3.09%, p=0.047), preoperative New York Heart Association class (HR=2.8, 95% CI 1.2% to 6.5%, p=0.015) and peripheral artery disease (HR=5.4, 95% CI 1.6 to 18, p=0.0054). Kaplan-Meier analysis showed that 1-year cardiac death was higher in the moderate-to-severe FTR group (p=0.048). In our study, 77% of pre-MitraClip moderate-to-severe FTR cannot be significantly reduced. Post-MitraClip moderate-to-severe FTR grade was related to lower survival (pConclusionIn patients with HFrEF treated with MitraClip for FMR, moderate-to-severe FTR was an independent predictor of cardiac death within 1 year. To improve survival, additional therapy to residual FTR should be considered in early phase after MitraClip therapy.

Surgical reoperation is still a standard procedure performed for degenerated aortic bioprostheses. On the other hand femoral minimally invasive valve-in-valve implantation (femTAVI-VIV) is an intriguing alternative. This clinical study was design to compare the early and late outcomes of redo-surgery (Redo-AVR) and femTAVI-VIV procedures for failed aortic bioprostheses.We retrospectively reviewed 108 patients with degenerated aortic bioprostheses qualified for isolated Redo-AVR (n = 40) or femTAVI-VIV (n = 68) between 2003 and 2018. Both cohorts were divided into intermediate and high-risk groups according to the EuroSCORE II (4-9% and9%). Propensity score matching selected 20 pairs in Intermediate-risk group and 10 pairs in High-risk group for the final comparison.Patients qualified for femTAVI-VIV were older (79.2 vs 72.9 years, p 0.001) and at higher risk (EuroSCORE II 10.9 vs 7.8%, p = 0.005) than Redo-AVR subjects. Overall survival in femTAVI-VIV and Redo-AVR was comparable at 30-days, 1- and 5-years, respectively (92.6% vs 92.5%, 85.2% vs 85.0% and 62.9% vs 72.5%, p = 0.287). After PSM no differences in mortality, myocardial infarction, pacemaker implantation, stroke or acute renal insufficiency were found. Transcatheter procedure was associated with shorter hospital stay, lower rate of blood products transfusions and higher incidence of mild paravalvular leaks.Our study supports the opinion that transcatheter approach for treatment of patients with degenerated aortic bioprostheses is a safe alternative to Redo-AVR procedures particularly for those at high-risk.

Objective: Transcatheter aortic valve-in-valve (TAVI-ViV) implantation is an established method to treat high risk patients with failed bioprosthesis. However, it can be associated with unfavorable...

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary cardiorespiratory support for patients in cardiogenic shock despite high-dose inotropic therapy and use of an intra-aortic balloon pump (IABP) [Muehrcke 1996]. Postcardiotomy cardiogenic shock has an incidence of 2%-6% after routine adult cardiac surgery [Hernandez 2007]. There are 0.5%-1.5% of patients who are refractory to medical and device therapy, and cardiogenic shock can lead to multiorgan dysfunction and mortality [Rastan 2010]. Prolonged cardiorespiratory support, which can be achieved with ECMO, may provide time for myocardial recovery and prevent multiorgan dysfunction and reduce mortality [Smedira 2001]. However, this device is associated with serious complications [Khorsandi 2017]. The reported survival rate on ECMO is 36% [Biancari 2018]. The aim of this study is to follow up on factors that can influence therapy outcome for patients who receive VA-ECMO after cardiac surgery.

Posterolateral thoracotomy was the access of choice in surgical treatment of patent ductus arteriosus (PDA) for many years before the introduction of video-assisted thoracoscopic surgery (VATS). The latter is thought to reduce postoperative pain and improve musculoskeletal system status. However, it carries a potential risk of conversion to thoracotomy.To evaluate the rate, reasons and outcomes of VATS conversion to thoracotomy in surgical PDA patients.From 2012 to 2017, 112 children were qualified for VATS closure of symptomatic PDA. Among them, 19 (16.9%) with the median age of 19.4 months required conversion to thoracotomy. The predominant reasons for conversion, early mortality and morbidity as well as late survival were evaluated.The overall conversion rate was 16.9% with an evident learning curve as it decreased significantly from more than 20% at the beginning to approximately 10% in the last 2 years. The predominant reasons were incomplete PDA closure (The rate of VATS PDA closure conversion to standard thoracotomy features a learning curve. Although it must be considered as a serious complication, probably it does not negatively affect either early the mortality rate or long-term survival.Tylno-boczna torakotomia przez wiele lat była dostępem z wyboru w chirurgicznym zamknięciu przetrwałego przewodu tętniczego (PDA), do czasu wprowadzenia techniki wideotorakoskopowej (VATS). Uważa się, że tę ostatnią cechują mniejsze dolegliwości bólowe i lepiej zachowany stan układu mięśniowo-szkieletowego, ale niesie ona ze sobą ryzyko konieczności konwersji do torakotomii.Ocena częstości i przyczyn konwersji VATS do torakotomii i wyników klinicznych takiego leczenia u pacjentów z PDA.W latach 2012–2017 do torakoskopowego leczenia objawowego zakwalifikowano 112 dzieci z PDA. U 19 z nich (16,9%), mediana wieku 19,4 miesiąca, konieczna była konwersja do torakotomii. W badaniu analizowano główne jej przyczyny oraz wyniki wczesne i odległe.Częstość konwersji dla całego czasu badania wyniosła 16,9%. Obserwowano krzywą uczenia, gdyż wskaźnik ten zmniejszył się z ponad 20% na początku do ok. 10% w 2 ostatnich latach. Głównymi przyczynami były: niezupełne zamknięcie przewodu (Częstość konwersji VATS do torakotomii podczas zamknięcia PDA cechuje krzywa uczenia. Choć konwersję należy traktować jako poważne powikłanie, to jednak nie wpływa ona niekorzystnie na wczesną śmiertelność lub przeżycie odległe.

Background: Patent ductus arteriosus (PDA) occurs more frequently in premature infants. Depending on the degree of prematurity, these children often have other serious comorbidities that could have a significant impact on surgical outcome. Aim: This study aimed to evaluate the clinical results of surgical ligation of PDA in extremely low body weight preterm infants with birth weight below 750 g, and to identify risk factors of mortality. Methods: A total of 31 preterm infants with birth weight below 750 g and significant PDA were operated between 2006 and 2016 through posterolateral thoracotomy (n = 16) or with the use of video-assisted thoracoscopic method (n = 15). Mean weight at the time of surgery was 750.8 ± 104.7 g. The gestational age ranged from 22 to 32 weeks. Data were retrospectively analysed, and prospective 100% follow-up was performed. Results: In-hospital mortality was 25.8% (n = 8). The type of surgery had no influence on the results. During the follow-up period lasting 5.2 ± 2.5 years, two other patients died. One-year and five-year probability of survival was 77.4% and 74.2%, respectively. The predominant cause of death was acute heart failure. All patients with preoperative renal dysfunction died in the postoperative period. Moreover, Cox regression analysis revealed renal dysfunction as an independent risk factor of early death. Conclusions: Preterm infants with birth weight less than 750 g and significant PDA are highly challenging patients. Despite the recent advances in perioperative management with neonates, surgery is still associated with a high early mortality rate irrespective of the applied method.

Ziel der Studie: Regelmasige korperliche Aktivitat hat sich als Therapieoption fur Patienten mit chronischer Herzinsuffizienz (CHF) erwiesen. Neben dem dynamischen Training zeigte auch eine Elektromyostimulation (EMS) der Skelettmuskulatur positive Einflusse auf die Belastbarkeit von CHF-Patienten. Die EMS-Therapie erfolgte mit einem System, das entweder simultan 8 grose Muskelareale elektrisch stimulierte (exEMS) oder nur die Gesas- und Oberschenkelmuskulatur (limEMS). Methodik: Es wurden stabile Patienten (NYHA II–III) mit chronischer Herzinsuffizienz fur ein EMS-Trainingsprogramm rekrutiert. Das Training wurde uber 10 Wochen, 2-mal wochentlich fur 20 min durchgefuhrt. 18 Patienten (11 mannlich; mittleres Alter 59,8±13,8 Jahre) erhielten exEMS-Training, 13 Patienten (10 mannlich, mittleres Alter 63,6±9,3 Jahre) erhielten limEMS-Training. Die Lebensqualitat (QoL – Quality of Life) wurde unter Verwendung des SF-36-Fragebogens vor und nach EMS-Therapie ermittelt. Die Auswirkungen auf die korperliche Belastungstoleranz (Sauerstoffaufnahme in der Spiroergometrie), die linksventrikulare Funktion (EF – Ejek­tionsfraktion) und die QoL wurden untersucht. Ergebnisse: Die QoL konnte in der exEMS-Gruppe in den Bereichen korperliche Funktionsfahigkeit (54,09±29,9 auf 75,45±15,6, p=0,048) und emotionale Rollenfunktion (63,63±45,8 auf 93,93±20,1, p=0,048) signifikant verbessert werden. In der limEMS-Gruppe zeigte sich eine signifikante Verbesserung im Bereich Vitalitat (37,5±6,9 auf 52,8±12,5, p=0,02). Die Sauerstoffaufnahme an der anaeroben Schwelle konnte signifikant gesteigert werden (exEMS +29,6%, p Schlussfolgerungen: EMS-Training fuhrt bei CHF-Patienten zu einer Erhohung der Sauerstoffaufnahme und der EF und zu einer Verbesserung der QoL. Das vorgestellte Konzept konnte eine sinnvolle alternative Trainingsmethode bei CHF-Patienten sein, die ansonsten nicht in der Lage sind, ein konventionelles Training durchzufuhren.

Electromyostimulation (EMS) of thigh and gluteal muscles is a strategy to increase exercise capacity in patients with chronic heart failure (CHF). The aim of this non-randomised pilot study was to investigate the effects of different stimulation strategies in CHF patients using a newly developed stimulation suit also involving trunk and arm muscles [extended electromyostimulation (exEMS)] in comparison with EMS therapy limited to gluteal and leg muscles (limEMS). 60 individuals joined the EMS training programme. Stable CHF patients (NYHA class II–III) received either exEMS (22 patients, 15 males, mean age 59.95 ± 13.16 years) or limEMS (12 patients, 9 males, 62.75 ± 8.77 years). 26 participants served as healthy control group (CG) receiving exEMS. Training was performed for 10 weeks twice weekly for 20 min, and the level of daily activity remained unchanged. Effects on exercise capacity, oxygen uptake, left ventricular function (EF) and biomarkers were evaluated. There was a significant increase of oxygen uptake at aerobic threshold in all groups (exEMS: 13.7 ± 3.9–17.6 ± 5.1 ml/kg/min (+28.46 %, p

Despite enormous progress concerning material and design, patients with artificial heart valves still face a considerable risk of serious complications (e.g., hemorrhage, thromboemboli, redos) which sum up to 4.9-22.4% for the first 10 postoperative years depending on type and position of the implanted prosthetic valve. Nowadays, technical defects of mechanical valves are negligible and relevant complications are rather a consequence of long-term anticoagulation therapy. To avoid these complications, the authors consider a strict control of both the anticoagulation therapy and the functional integrity of the prosthetic valve to be inevitable. Therefore, with the aim of risk minimization the patient should be enabled to cooperate by means of methods which are easy to handle in his everyday environment. First multicentric results of a new method of early detection of valve dysfunction are presented.

BACKGROUND: Several risk factors for early mortality after intra-aortic balloon pump (IABP) implantation have been described. METHODS: We performed a retrospective analysis in 120 patients receiving peri- or postoperative IABP support. Univariate and multivariate analyses were carried out to assess variables potentially influencing 30-day mortality in order to develop a risk score for the prognosis of survival and for the decision on optimal patient-specific treatment. RESULTS: The 4 parameters (mean arterial pressure, adrenaline dose, central venous pressure, and blood lactate concentrations) at 6 hours of IABP use were independently related to 30-day mortality. They were used to develop a risk score (0 - 4 points). With this score, patients who scored 3 or 4 points had no probability of surviving, whereas patients with a score of zero had a probability of 84.4 %. A prospectively screened cohort of 145 patients confirmed the reliability of our risk score. CONCLUSIONS: Our data demonstrate that a score can predict 30-day mortality in patients with IABP implantation. Such a score can be useful to find out whether or not ECMO/VAD implantation is necessary.

Background Because of increasing life expectancy of patients with heart valve replacement and a limited durability of heart valve bioprostheses, cardiac reoperation becomes necessary in a significant percentage of patients. Reliable data on mortality and risk factors in octogenarians after replacement of aortic valve prostheses are scanty, however. Methods We retrospectively analyzed 71 patients aged 80 years and older who underwent cardiac reoperation of the aortic valve (69 bioprostheses, 2 mechanical prostheses) between 1991 and 2004 at our heart center. Survival rate of the study cohort was compared with a control group of octogenarians matched for age, sex, and year of aortic valve replacement. To assess predictors of 30-day survival and 3-year survival, we performed univariate and multivariate analyses. Results Survival rates at 30 days, 1 year, 3 years and 5 years were 83.6%, 76.1%, 70.8%, and 51.3%, respectively. Results did not differ significantly between the study cohort and the controls. Patients with reoperation had an estimated median survival of 5.6 years. Postoperative complications such as low cardiac output syndrome and intestinal failure were the only independent predictors of 30-day survival ( p = 0.020 and p = 0.015, respectively). Low cardiac output, intestinal failure, and diabetes mellitus were independent predictors of 3-year survival ( p = 0.001 to 0.033). Conclusions Our data demonstrate that it is possible to achieve an acceptable outcome in octogenarians who have reoperation of the aortic valve prosthesis. Early and mid-term survival is predominantly influenced by unexpected postoperative complications and not by preoperative risk factors, with the exception of diabetes mellitus.

Aufgrund der gestiegenen Lebenserwartung von Patienten mit Herzklappenersatz sowie einer begrenzten Haltbarkeit biologischer Klappenprothesen wird bei einem signifikanten Prozentsatz der Patienten eine Reoperation im Alter von ≥80 Jahren notwendig. Es liegen jedoch nur wenige Daten zur Letalitat nach Ersatz einer biologischen Prothese vor. Deshalb wurde bei 56 Patienten im Alter von ≥80 Jahren, die im Zeitraum von 1991 bis 2004 aufgrund einer Klappendegeneration am Zentrum der Autoren reoperiert wurden, eine retrospektive Datenanalyse vorgenommen. Mittels uniund multivariater Cox-Regressionsanalysen wurden Einflussfaktoren auf die Uberlebensrate untersucht. Die mittlere Uberlebensdauer der Patienten betrug 5 Jahre. Die 30-Tage-, 1-Jahres-, 3-Jahres- und 5-Jahres-Uberlebensraten lagen bei 81,1%, 71,3%, 67,5% und 50,8%. Lediglich das Low-Output-Syndrom und Darmischamien erwiesen sich als unabhangige Pradiktoren sowohl der 30-Tage-Letalitat als auch der 3-Jahres-Mortalitat. Postoperativ kam es zu einer deutlichen Verbesserung des NYHA-Stadiums, und die Mehrzahl der Uberlebenden war in der Lage, eigenstandig zu Hause zu leben. Die Daten zeigen, dass es moglich ist, akzeptable Ergebnisse bei ≥80-Jahrigen nach Ersatz der Klappenprothese zu erzielen. Sowohl die fruhe als auch die mittlere Mortalitatsrate sind vorwiegend von unerwarteten postoperativen Komplikationen beeinflusst. Somit ist eine Reoperation der Aortenklappe selbst bei Patienten dieser Altersgruppe vertretbar.

Purpose The purpose of this study was to investigate whether: 1. sound phenomena may be used to detect prosthetic valve dysfunction; 2. clinical and experimental data permit conclusions about alterations in the functional state of mechanical valves; 3. patients can record and pass on signals via Internet. Methods 1. We implanted bi-leaflet valves in pigs. By gradually influencing the motion of the tilting discs prosthetic dysfunction could be generated. 2. Thrombosis and lysis of bi-leaflet valves was studied in sheep. This process was documented using echocardiography and acoustically by the Fast Fourier Transformation. 3. Thirty devices were set up and handed out to patients following mechanical valve replacement. All patients regularly sent data to the hospital via Internet, regardless of their location at the time. The data were evaluated by comparing them with the reference file. Results Animal experiments proved that changes in prosthetic function led to a significant change in sound phenomena. In contrast to echocardiography alterations at an early stage (onset of thrombosis) could be reliably verified. The sensitivity was greater than in echo-control analysis. All patients regularly recorded and passed on their signals. Surveys revealed high acceptance and easy handling of the devices. Conclusions Online registration of sound phenomena seems to be suitable for the detection of changes in prosthetic function. This led to the development of the first hand-held device for home monitoring of valve function. Registration of flow, frequency spectrum, and ECG envisaged at the next level opens up potential applications for Internet-based, remote monitoring of cardiac patients.

Background Operative outcome of simultaneous carotid endarterectomy and valvular surgery has not been clarified. We retrospectively reviewed short-term and long-term outcomes after carotid endarterectomy combined with valvular replacement. Methods Seventy-nine patients (50 men and 29 women. mean age, 68.9 ± 6.9 years; range, 53.3 to 78.7 years) underwent carotid endarterectomy combined with valve replacement from February 1985 to April 2002. Indication of carotid endarterectomy was more than 75% carotid stenosis with or without ulceration. Thirteen patients had history of stroke. Endarterectomy was performed under mild hypothermia with cardiopulmonary bypass in all cases. Positions of replaced valves were aortic in 64 patients, mitral in 10, and mitral and aortic in 5 patients. Results There were 8 early deaths (10.1%). Early neurologic complications occurred in 8 patients (10.1%); two late events were observed. Double valve replacement was an independent risk factor for early death (p = 0.039; odds ratio=25.6). For early stroke we found no statistically significant risk factor. Myocardial infarction (p = 0.022; odds ratio=3.0) and age more than 70 years (p = 0.03; odds ratio=2.5) were independent risk factors for premature death; we found no independent risk factor for late stroke. Permanent impairment or death as a stroke consequence was seen in 5 patients, 3 of them had ipsilateral strokes, 2 had contralateral strokes. Conclusions Endarterectomy can be safely performed combined with aortic valve surgery. Concomitant mitral or double valve replacement cannot be judged reliably because of the small number of patients, but they might be a high risk.

In a series of experiments, the planktonic larvae of Marenzelleria viridis (Verrill. 1873) were exposed to various combinations of salinity (S = 0.6.2.5.5.0.10 and 20%o) and temperature (T = 5.10 and 20°C) from the 1 -setiger stage to the onset of metamorphosis (16- to 17-setiger stage). One-setiger larvae were unable to complete their development to metamorphosis at salinities below 5%». Metamor- phosis was successful at salinities of 10 and 20%o. when the animals adopted a benthic life mode. Larval development was more rapid at 10%o than at 20%o, and was positively affected by higher temperatures. Larvae exposed to a salinity of 3.5%o at the 4- to 5-setiger stage developed and completed metamor- phosis to benthic juveniles despite the low salinity. These larvae developed most rapidly at a tempera- ture of 10°C. The salinity tolerances (LC,,) of M. viridis larvae ((= 48 h). juveniles and adults (r = 72 h in each case) were determined at 10°C. The results showed that all development stages can tolerate salin- ities

The metabolic activities of different developmental stages of the polychaete Marenzelleria viridis (Verrill 1873), which has successfully populated Baltic coastal waters since the 1980s, were determined under different temperatures, salinities and oxygen partial pressures by simultaneous calorimetry and respirometry. Larvae of M . viridis maintained their metabolic activity and met this fully aerobically down to severe hypoxia. Adult individuals gradually reduced their metabolic activity with decreasing oxygen partial pressures. An additional hyposmotic stress of 0.5‰ salinity, referring to low salinities in the biotope, led to an approach of the response of M . viridis to the oxyconformer model. The results for adults were compared to those of the common indigenous polychaete Nereis (Hediste) diversicolor (O.F. Muller), which responded with maintained metabolic activities to hypoxia. The ecological efficiency of the different adaptation strategies to hypoxia are discussed. ecological efficiency of the different adaptation strategies to hypoxia are discussed.

Transcatheter aortic valve implantation (TAVI) is used as an alternative to conventional surgery in high-risk patients. The EuroSCORE quantifies the risk, and patients are selected for this procedure if their predicted mortality is high. The study aim was to evaluate the risk discrimination and calibration of the EuroSCORE, as well as the surgical judgment that is used when selecting the aortic valve replacement (AVR) approach.Between 2003 and 2006, a total of 2757 patients underwent isolated, open AVR. The EuroSCORE was compared to the observed in-hospital mortality. A survey among surgeons assessed the relevance of patient-specific factors towards the approach of TAVI versus open AVR.Survivors of AVR had a lower additive EuroSCORE than non-survivors (7.2 +/- 3.34 versus 12.0 +/- 3.34; p0.001). The EuroSCORE demonstrated reasonable risk stratification (c-statistic 0.843, p0.001). However, none of the 67 non-survivors was correctly predicted (Hosmer-Lemeshow test; p0.001), and most patients with a high EuroSCORE survived AVR. The actual mortality was 2.8% as compared to a EuroSCORE-predicted mortality of 12.5 +/- 14.2% (p0.001). This poor calibration was worse with higher EuroSCOREs (Cusum test; p0.001). Surgeons identified a porcelain aorta as the only factor that warranted TAVI. Most EuroSCORE variables had either no relevance for treatment selection, or prompted open AVR.Patient selection for TAVI cannot be based on the EuroSCORE, because it lacks discrimination and center-specific calibration. Thus, individual, surgical judgment that weighs institutional expertise for high-risk patients against a possible reduction of mortality by using interventional techniques, is recommended.

The majority of patients with migraine headaches are treated in non-specialized institutions though data on treatment outcomes are largely derived from tertiary care centers. The current non-interventional study explores efficacy and tolerability outcomes of patients with episodic migraines receiving topiramate as preventive agent in a general practice setting. A total of 366 patients (87% female, mean age 41.8 ± 11.6 years) were eligible for migraine prevention and treated with flexible dose topiramate for 6 months (core phase), and optionally for a total of 12 months (follow-up phase). Overall, 261 patients (77.7% of safety analysis set, SAF) completed the core phase. Reasons for discontinuation included adverse events (2.1%), lost to follow-up (1.8%), other reasons (1.5%), and end of therapy (0.3%) though in the majority of patients who discontinued no reasons were listed. The median daily dose at endpoint was 50 mg/day (range, 25–187.5 mg/day). The median days with migraine headaches decreased from 6.0 to 1.2 days (p

Prosthetic heart valve dysfunction impacts on morbidity and quality of life. Although the diagnosis can be made by imaging studies, clinical symptoms commonly precede the diagnostic work-up. The ThromboCheck device analyzes the sound frequency spectra of valve motion, and alterations due to valve dysfunction are observed before overt clinical symptoms develop. The study aim was to determine if the ThromboCheck can be used to monitor the prosthetic valve function of patients at home.Between 2003 and 2007, a total of 541 prosthetic heart valve recipients was prospectively enrolled into a double-blind, multi-center study. ThromboCheck devices were used to evaluate the sound frequency phenomena of valve motion. If the sound frequency spectra deviated from baseline, alarm signals were returned to the medical center via telephone, and these prompted evaluation by fluoroscopy and echocardiography. The clinical follow up included questionnaires at regular intervals.The cumulative observation period exceeded 748 patient-years, with a median follow up of 25.2 months per patient (range: 1 to 36 months). Almost all patients used the device at least two to three times per week to evaluate valve function, and the vast majority found it easy to operate. About 135,000 codes were returned to the study centers for further analysis; of these codes, 30 (0.0002%) were alarm signals. On 29 of the 30 occasions, prosthetic valve dysfunction was confirmed by fluoroscopy and echocardiography, yielding positive predictive values and specificities of 97% and 100%, respectively. There was no clinical event in the absence of a ThromboCheck alarm signal. Thrombolysis or increased warfarin-based anticoagulation quickly restored the initial sound frequency spectrum of the prosthetic valve in 16 patients. Another 13 patients were surgically revised; their prosthetic valves revealed significant thrombi upon replacement. By using the ThromboCheck device as part of a surveillance system, 79% of the patients felt safer with regards to prosthetic valve dysfunction.Analysis of sound frequency spectra by the ThromboCheck identified prosthetic heart valve dysfunction before clinical symptoms developed, and promoted early therapy. The restoration of valve function normalized the frequency spectra, which may be utilized to guide treatment. These results justify further efforts to introduce the analysis of sound phenomena into routine clinical care after prosthetic valve implantation.

Although prosthetic valves are durable and easy to implant, the need for lifetime warfarin-based anticoagulation restricts their exclusive usage. We investigated if anticoagulation self-management improves outcome in a single-center series.Between 1994 and 1998, 765 patients with prosthetic valve replacements were prospectively enrolled and randomized to receive conventional anticoagulation management by their primary physician (group 1, n = 295) or to pursue anticoagulation self-management (group 2, n = 470). A study head office was implemented to coordinate and monitor anticoagulation protocols, international normalized ratios (INR), and adverse events. Patients were instructed on how to obtain and test their own blood samples and to adjust warfarin dosages according to the measured INR (target range, 2.5 to 4).Mean INR values were slightly yet significantly smaller in group 1 than in group 2 (2.8 +/- 0.7 vs 3.0 +/- .6, p0.001). Moreover, INR values of patients with conventional INR management were frequently measured outside the INR target range, whereas those with anticoagulation self-management mostly remained within the range (35% vs 21%, p0.001). In addition, the scatter of INR values was smaller if self-managed. Freedom from thromboembolism at 3, 12, and 24 months, respectively, was 99%, 95%, and 91% in group 1 compared with 99%, 98%, and 96% in group 2 (p = 0.008). Bleeding events were similar in both groups. Time-related multivariate analysis identified INR self-management and higher INR as independent predictors for better outcome.Anticoagulation self-management can improve INR profiles up to 2 years after prosthetic valve replacement and reduce adverse events. Current indications of prosthetic rather than biologic valve implantations may be extended if the benefit of INR self-management is shown by future studies with longer follow-up.

Background After heart valve replacement, patients are at risk of complications that are linked to irregular oral anticoagulation therapy. Depending on the type and position of the valve, the complication rate is 3% to 6% per patient-year. This study presents clinical results of a device enabling early detection of prosthetic dysfunction by frequency measurements. Methods Between November 2003 and March 2006, ThromboCheck devices were handed out to 483 patients after mechanical heart valve replacement from six heart centers. In each case, the devices were calibrated for individual patients early postoperatively. Taking control measurements, the device calculated deviations from calibrated frequency and amplitude ranges using a fast Fourier transform and sent a warning message to the display if any relevant changes occurred. This message was taken as cause to determine morphologic correlations of the disturbance using imaging techniques, for example, echocardiography or fluoroscopy (observation period, 550.7 patient-years; median application period, 15.1 months). Results Twenty-five true positive, 1 false positive, and no false negative measurements occurred. Eleven patients (44%) received thrombolytic therapy with streptokinase or recombinant tissue-type plasminogen activator, resulting in normalization of the digital frequency analysis. In 4 patients (16%), international normalized ratio levels were adjusted under temporary heparinization therapy. Normalization of the valve sounds were achieved within 3 to 7 days. Seven patients (28%) required reoperation despite lysis therapy. Sensitivity was 100% during the observation period; specificity was 99.8%. Conclusions Digital frequency analysis represents a reasonable addition to the monitoring of patients after artificial heart valve replacement to detect prosthesis-related complications early on.

Depending on the individual risk profile of a patient, disturbances of the functional integrity of mechanical heart valve prostheses occur in up to 2.5% of patients each year. The early phase of prosthetic dysfunction (due to thrombus formation, tissue ingrowth or endocarditis) usually remains undiagnosed, as patients do not present with symptoms in this situation, and imaging techniques (echocardiography, fluoroscopy) demonstrate normal occluder motion. The delay between the onset of prosthetic valve dysfunction and its clinical manifestation may result in complications (e.g. thromboembolism) or extended therapeutic options (e.g. reoperation rather than more intensive anticoagulation).A total of 291 patients with mechanical heart valves was allocated to four different sub-groups, and each measured their valve sounds regularly with the 'ThromboCheck' device. Depending on the subgroup, the signals were compared with different reference signals. Patients in whom a suspicious signal was detected were immediately contacted and examined meticulously.Fourteen patients were found to have suspicious signals. In 13 patients, valve dysfunction was confirmed by fluoroscopy, but in four cases neither transthoracic nor transesophageal echocardiography detected abnormal occluder motion or 'musses' adjacent to the prosthesis. Normal valve sounds returned in four patients who underwent thrombolytic therapy. All patients regularly recorded and passed on their signals. Surveys revealed high acceptance and easy handling of the Thrombocheck device.Home monitoring of sound pressure measurements of prosthetic valves by digital frequency analysis via a Fast Fourier transformation may detect even very mild alterations of prosthetic valve function. The next evolution of control systems, allowing for registration of flow, frequency spectrum and electrocardiography, opens potential applications for Internet-based, remote monitoring of cardiac patients.

Patienten mit einem alloprothetischem Herzklappenersatz haben trotz erheblicher Fortschritte hinsichtlich des Materials und des Designs der Prothesen noch immer ein Risiko eine ernste Komplikation (Blutung, Thrombembolie, Re-Operation) zu erleiden, welches sich in den ersten 10 postoperativen Jahren je nach Klappentyp und Klappenposition auf 5–20% summiert. Dabei sind technische Defekte an mechanischen Herzklappen heute zu vernachlassigen. Vielmehr sind relevante Komplikationen im Langzeitverlauf haufig mit der korrekten Antikoagulation verbunden. Um diese zu vermeiden, erachten wir eine moglichst engmaschige Kontrolle sowohl des Gerinnungsstatus als auch der funktionellen Integritat der Herzklappenprothese als unabdingbar. Dabei kommt es wesentlich darauf an, den Patienten selbst in die Lage zu versetzen, mittels einfacher und beliebig oft in seiner alltaglichen Umwelt durchzufuhrender Methoden an der Risikominimierung mitzuwirken. Wir stellen eine zuverlassige Methode vor, mit der vom Patienten ohne groseren Aufwand beliebig haufig die funktionelle Integritat seiner Kunstklappe uberpruft werden kann.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a cardiomyopathy that primarily affects the heart muscle in the right ventricle. The ventricular muscle is replaced by fatty or fibrous tissue in a diffuse or spotty process. We performed orthotopic heart transplantations in 3 patients and all patients are alive. When ARVC has progressed to heart failure in the right or left ventricles, orthotopic heart transplantation is an effective therapeutic option.